Airway Workshop

EMERGENCY MEDICINE

MEDICAL STUDENT’S AIRWAY SESSION

PDF handout – AIRWAY WORKSHOP FINAL

Word handout – AIRWAY WORKSHOP FINAL

• Assessment of Airway and Breathing

In order to assess airway and breathing: ‘DR-ABC’:

• Check for
  1. Danger
  2. Responsiveness of patient
  3. Open the airway with basic manoeuvres
     1. jaw thrust
     2. head tilt chin lift
  4. Remove obvious obstructions from the airway
  5. Listen, Look and Feel for Breathing

• Ventilation Devices – BVM
  • Key Points to Successful Ventilation:
    • Remember to connect the device to an Oxygen Supply
    • Use two providers wherever possible (see External Study)
    • Maintaining a good seal is important for ventilating the patient.
    • This is done in basic terms by lifting the face into the mask and applying a steady downward counter pressure to the mask.
    • Try placing your little, ring and middle fingers of your left hand on the mandible in the shape of the letter ‘M’ and your thumb and fore finger on the mask in the shape of a ‘C’.
    • Now ask a colleague to squeeze the bag to Ventilate.
    • Don’t ‘bag’ too fast or hard – we recommend aiming for 10-12 breathes / min
      • average rate of ventilation can be >40 per minute in cardiac arrests (see External Study)
    • If ventilation remains difficult consider an Adjuvant Device (see below)
    • Patients receiving BVM for cardiac arrest can do as well if not better than those who are intubated (see External Study)

• Failure to Ventilate
  • associated with ‘MOANS’:
    •  Mask Seal (Size, hands, shape, beard, trauma)
    • Obesity/Obstruction (Resistance, shape, faster desaturation)
    • Age (Over 55 and pregnant women are harder)
    • No Teeth (Face ‘falls’ inward)
    • Stiff Lungs (Asthma, COPD etc)

ADJUVANT DEVICES

• Commonly used adjuvant airway devices include the OROPHARYNGEAL and NASOPHARYGEAL airways:

In the case of difficult ventilation in a patient who is not breathing or in the unconscious patient who is still breathing these devices may help you maintain the airway:

• Nasopharyngeal Airway
  • Apply Lubricant and consider placing a pin through airway
  • Place through nostril with a slight twisting motion straight back into nasopharynx
  • Attempt to ventilate Patient with bag mask
  • Avoid use in head injuries, facial injuries and with epistaxis

• Oropharyngeal Airway
  • For adults size the airway from the tragus of the ear to the edge of mouth
  • Insert upside down and rotate backwards over the tongue
  • In children place the device in the ‘right way round’ to avoid trauma to the upper oropharynx

SUPRAGLOTTIC DEVICES

ENDOTRACHEAL INTUBATION

A systematic assessment of the Airway is important prior to attempting intubation.  A thorough pre-op assessment is a cornerstone of modern anaesthesia.  In order to assess the ‘potential difficulty’ of intubation – we can use the ‘LEMON’ law:

1. Look
2. Evaluate ‘332’
3. Malampatti Score
4. Obstruction
5. Neck

Endotracheal Intubation (Key Points)

• Prepare your Equipment in Advance of Procedure
  • You will need appropriately sized endotracheal tubes, suction (working), equipment for ventilation (bag mask), pillow or head ring for head position, adjuvant equipment such as introducers and alternative blades to hand.
  • Head position – Does the tragus of the ear line up with the sternal notch?

• Check the Laryngoscope is working (is the light on?)
• Hold handle in Left Hand (right hand is free to move the head and hold the tube)
• Place the Laryngoscope blade into the Right side of the mouth with help of an assistant if necessary
• Sweep the Tongue across to the left in order to push it out of the way…
• Insert the blade until you Visualise the Epiglottis

• Lift the Laryngoscope Handle forward with steady force (do not ‘lever’ teeth)
• Look to Visualise the Vocal Cords

• Optimise your view if necessary using “30 second drills“

• Place the tube or gum elastic ‘boogie‘ through the cords (and ensure to visualise it going through).

   

• Be careful not to put ET tube in too far (if you do you may go past the carina and only ventilate the right lung)
• Connect the Bag and Valve Mask, Ventilate the Patient Gently and then Inflate the Cuff until any leaks disappear
• Connect the End Tidal CO2 (trace and tubing pictured below)

   

• Check the air entry on both sides in 3 positions to ensure equal air entry and then Secure the ET tube with tape or tie
• Document in the patient’s medical record

Equipment

Various equipment must be prepared prior to advanced airway management.

The commonly used laryngoscope ‘blades’ include the MACINTOSH, MCCOY and MILLER types:

Other Methods for Intubation

Other complex techniques are used selectively by airway specialists (anaesthetists) for securing an airway. These may include ‘awake’ intubation by ‘blind nasal’ route or ‘fibreoptic’ method. This is often facilitated by the use of sedation and local anaesthesia. In addition recent developments in technology have increased the availability of devices such as the “C-mac” and “Glide Scope“. This is likely to be widely available in the future and provides excellent views on an electronic viewing screen but is currently retailing at around 15000 dollars and is therefore not available in all Australian hospitals.

Rapid Sequence Intubation (RSI)

“Rapid sequence induction (RSI) is the standard procedure for prompt induction of anaesthesia and subsequent intubation used in the Emergency Department and ICU as well as in selected cases in the Operating Theatre.”

CLICK HERE for more information about RSI

A CHECKLIST is recommended when carrying out this complex and challenging team based procedure

EMERGENCY SURGICAL AIRWAY